Category: Uncategorized

Introduction

Remote medical coding professional perks- working from home, no morning commute, flexible schedule, comfortable work clothes, ability to completely control your environment (room temperature, room lighting, sound considerations ) compared to other office workers to name just a few. But I know there is one area, that no one would list as a perk, and that is productivity, the job requirement to meet a number quota of so many charts per hour. I know some who might be neutral on the topic or proud that it’s not a struggle they have, but I have never meet anyone who loves this part of the job. Tolerate it, yes. Know that if you want to collect a paycheck it’s required, yes. Even be able to argue that it is within a company’s right to expect this from it’s employees in exchange for income, yes. However, I”ve never met anyone who loves this aspect of the job. Nobody will ever look at you with envy when you mention, “And I’m electronically monitored on the job, the numbers of charts I produce each day and if I don’t meet that number , I’ll have to talk to my boss about it . And each day I start at zero and I’ll have to fill my chart quota bucket accordingly. “

When the topic of working from home comes up, I’m often asked, “How do you not get distracted and do laundry, washes dishes or watch TV instead of work at your desk ?”. But really, thats not a temptation for me since I know I won’t meet my numbers if I do those things during non break times. Advanced computer programs allow a lot of monitoring now, so how I use my time exactly shows up as data and I work for a place that does daily reports on productivity and daily peer bench marking in terms of coding productivity. Computer generated reports show if I’m meeting those numbers or not.

But while it’s not something I love about my job, I work on getting more efficient with my coding so it’s not such a burden and I strive to manage the stress and not let it overwhelm me or sour my mood too much on the hard days. Here are some way’s I deal with the job requirement of productivity.

Here is an example from today. My second chart of the day was very complicated. It took three times what the standard chart take time wise. I need to complete 4.5 charts per hour. The time period when I did this chart, I ended up coding just two charts. I’m now in the hole 2. 5 charts and I’m only on my first hour of the day. My mind immediately goes to, “It’s going to be a bad day number wise. I won’t be able to make this up. It’s all downhill from here. I’m screwed. ” This is a dangerous attitude to have in terms of productivity because once you start to feel you can’t make the chart number quota for the day , you start to give up, you start to move through the chart slower and you start to diddle dwaddle since the day is no longer perfect. My progress is not moving in a straight line. It was looking like a no lunch, just snacks at the desk in order to save time day compounded now by my lack of enthusiasm and lost focus because the day is not going how I wanted.

But the afternoon had some pleasant surprises. I hit some very easy charts in the work queue, and was able up to make up the lost time and meet the numbers for the day. If the day was compared to a football game , it would have been similar to a game where the team was losing by two touch down’s at half time but had a miraclous fourth quarter and the team managed to win the game despite it’s rough start. To get the victory though in football and in coding, does require one to believe that it is possible, that you have the stamina and fortitude to pull it off. Giving up to quickly does not help.

Tip 2 : To increase your speed, increase your knowledge

I have been an outpatient surgical coder for a large, five hospital facility system for 3 years now. The surgery and observation team does not separate out the work by having certain coders code certain things such as some coders are only orthopedic coders or are spine coders or are gastrointestinal coders, etc. We code whatever chart we land on in the work queue. We are all general surgery coders for a trauma 1 hospital and 4 community hospital’s. My work day zig zags from colonoscopies, orthopedics, eye surgeries, hysterectomies, spine surgeries, gall bladder removals, all different surgeries. Because of that, I have a large span of things that I code and that I need to have some experience with in order to make the quality requirement of 96 % (a whole other blog post ) . There are some things that I only see every few months since the work is divided up between 14 other coders and some things are complications or just not your bread and butter typical surgeries like gallbladder removal or screening colonoscopy or breast lumpectomy. Because of this, I make it a point to save examples, notes, emails or other references I found helpful when I coded that difficult surgery the first time. I use to print these references and save them in binders, but now I use Microsoft OneNote which is a great program that has wonderful tabs and search options in it. My point is, make it easier for yourself in the future. By saving your insights, code selection or coworker emails now, that future chart will only take you twenty minutes instead of the 30 to 45 it took today because of all the extra research you had to do before you could complete it. Investment in your education today, brings added speed, mental energy and confidence later.

Tip #3: Set yourself up for success, pick hours that will bring maximum concentration and minimal distraction

I do best energy wise and mentally if I work early morning. The house is super quiet, I’m the only one up in my house and the computer system at work, runs faster since there are less people on the network and less emails going on to distract you. There are also less people in the work queue so you can move between charts faster also. Because of all these small factors, I’m a huge fan of early morning coding and code the most charts early morning. I lose speed as the day goes on.

I’ve also noticed, I do best with a broken up schedule. I like to work extra on Sunday so I can work shorter days during the week. I have coworkers who like to break up their hours, four hours in the morning, then an afternoon break of a few hours and then work again mid afternoon for four more hours. This is a job that requires a lot of sitting, staring at computer screens. On the bad day’s number wise, breakfast and lunch can be eaten at the desk to save time and bathroom breaks are minimal. A flexible or broken schedule can do wonders for your physical body and to refreshen your mind. Coding may not wear you out physically but it can be very tiring mentally.

Another energy tip that helps me is, if I land on a very difficult chart late afternoon in the coding queue , I will save that chart and code it tomorrow morning when I’m at my best and my mental energy bucket is full again. When I’m depleted mentally, I move slower and I can make more mistakes because I’m not thinking clearly. The best thing I can do in that moment is to save that chart and code it tommorow morning. I don’t always have that option, but if I do, that is my best line of defense to protect against coding mistakes and lost productivity due to being mentally tired.

This is just a small sample of ways to think about productivity. Everybody has their own personal way of dealing with it and improving. Some days its easy peasy to make the numbers and other days, I totally miss the mark. But I know its a requirement that is never going away so best to make my peace with it and manage it the best way I can.

Introduction

While researching tibia tubercle tuberosity osteotomy, MPFL reconstruction was another surgery I also learned is commonly done for patella instability.

The MPFL ligament often becomes injured when the kneecap is dislocated. Patients with an underlying abnormality of the knee, or those with ligament laxity or weak leg muscles are at an increased risk for patella dislocations, as are individuals involved in sports or other activities that involve pivoting.

The MPFL plays an important role in keeping the patella on track and in place. It acts as a leash that restrains the movement of the patella. When patella dislocation occurs, the patella jumps the track and then comes forcibly back into place on its return. The patella bone always dislocates laterally, towards the outside part of the leg. When the patella returns into place it pulls down hard on the medial patellofemoral ligament causing ligament tearing, injury and cartilage damage.

Anatomy

This procedure involves ligaments and it helps to understand what they do to get a deeper understanding of this procedure. Ligaments connect bones to other bones to form joints. They are made of soft connective tissue and have a very low blood supply compared to muscles, making them very slow to heal and recover from injury.

The medial patellofemoral ligament is a ligament that connects the patella to the femur and allows the knee to pivot and shift. It is considered an extra-articular ligament, meaning it’s on the outer aspect of the knee joint. There is another extra-articular ligament, the lateral patellofemoral ligament but I have yet to see this ligament repaired with reconstruction like I do for the mpfl. For your cpt selection you will need to select extra-articular or intra-articular, that is the key difference for the ligament reconstruction codes cpt 27427 (extra-articular) cpt 27428 (intra-articular open) and cpt 27429 (both, intra-articular and extra-articular).

Intra-articular ligaments are the anterior cruciate and posterior cruciate ligament. The medial collateral ligament and the lateral collateral ligament are also intra-articular, but they are less frequently injured and rarely require surgical reconstruction or augmentation.

Procedure

Diagnostic arthroscopy is usually done to inspect the cartilage and to see if there are any other injuries or disease processes that can be addressed during surgery.

Once the arthroscopic inspection is done, the ports are removed and the open portion of the surgery begins. The physician makes an incision over the injured ligament. The torn end may be reattached to the bone using anchors, staples, screws or washers. If reattachment on its own is not possible, the ligament is reattachment with a tendon autograft ( graft from self- think autograph) or allograft (same species, different person-cadaver ).

Websites to learn more

Here are some good websites and a YouTube video to learn more about the procedure.

Introduction

Today, I would like to write about the orthopedic knee procedure, tibia tubercle tuberosity osteotomy. The purpose of the surgery is to improve alignment of the patella. This is achieved by making a bony bridge from the tibia tubercle and moving it, with its attachment of the patella tendon more medially than its original location. A process often called by the Surgeon anteriormedialization translation (moving the patella tendon/tibia tubercle tuberosity medially on the anterior side of the knee) . Other common names for this procedure are:

Anatomy

The tibia tubercle is an oblong major bony ridge elevation on the tibia that provides an attachment point for the patella tendon. It acts as a lever for the patella tendon during extension and helps give the patella stability. If the patient is having patella instability, painful patella maltracking (patella is not staying in place) and symptoms of arthritis, one surgical option to correct this is tibia tubercle osteotomy (surgical cutting of a bone or a removal of a piece of bone.)

Procedure

The surgery initially begins with a diagnostic arthroscopic inspection (included in the surgery, not separately charged). Visual analysis of the articular cartilage takes place to see if there is any damage or defects in the cartilage. If found, a tool (burr, arthrocare ablation wand or shaver ) is attached to one of the scope’s. Next, debridement and shaving for clean up of the articular cartilage are done ( chondroplasty cpt 29877 can be charged if done). At the end of the arthroscopic section of the surgery, the scope is removed and the open procedure begins.

Now, the osteotomy , the cutting of the tibia tubercle begins.

An incision is made lateral to the patella and carried down along the distal anterior ridge of the tibia. Muscles involved in the extensor mechanism, over the anterior compartment are elevated. An incision is made through the periosteum of the tibia bone, distal to the tuberosity. K- wires are placed, a medial osteotomy is made that follows the plane of the K- wires followed by a lateral osteotomy cut. Oscillating saw and osteotome tools are used to perform these cuts. The tibial tuberosity is then repositioned in its new position. Patella tracking is assessed to check for misalignment or continued maltracking. Once proper alignment is achieved, one or more screws are drilled into the bone to secure the tibial tuberosity bony bridge in its new location.

To learn more about this procedure, check out this YouTube video on it. There are two other common patella procedures, I will blog on next.

Attention to Detail

Blog disclaimer- my spices are not in alphabetical order. A few socks in my sock drawer are missing mates. My desk is 75% organized, but does have some pens, papers and other random things on it not related to my job at all. Because of this, I cringe a bit with the mandate , “must be attentive to detail,” to be a great coder. I can’t 100% identify with that label and say, yes that’s me exactly because I know I have parts of my life where I’m okay not having all the details worked out such as my spices, my desk, my socks, etc .

But others I know, identify strongly with this attribute and do have examples in their life other than coding that can testify to this attribute so I concede it is an attribute that is part of medical coding.

Problem Solver

While the attention to detail label is not my favorite description of the job, I do definitely embrace the label of being a problem solver, someone persistent in trying to figure this operative note out and someone willing to die on the treadmill as Will Smith describes-

“The only thing that I see that is distinctly different about me is I’m not afraid to die on a treadmill. I will not be out-worked, period. You might have more talent than me, you might be smarter than me, you might be sexier than me, you might be all of those things you got it on me in nine categories. But if we get on the treadmill together, there’s two things: You’re getting off first, or I’m going to die. It’s really that simple, right?”Will Smith

There are times you will need to be persistent and query the physician to get the answers you need. Other times, will require you to email a co-worker one more time for guidance, put more time into your google searches or for you to pull out the medical dictionary or coding desk reference again and break the terms down one more time even though you have already put so much time into this account, your productivity numbers are terrible this hour. Your answer will come from sweat and tears and not obsessive attention to detail at times.

But even problem solving has its limits in being effective and another skill must be relied upon and developed in order to be fully successful on the job.

Expansive thinker

This is a skill, not listed at all when it comes to medical coding, but I think its one that definitively needs to be added. There will be times when you have exhausted your zoom in skills- attention to detail, problem solving, and now need the skill of expanding your thinking and zooming out your focus. Here is an example- unlike coding for a credentialing exam, the title of the op report and the body of the op report will not always match like they do on a exam. One must really study the operative report to see if the title matches the body of the op report. Changes might have had to occur and the surgeon did not update the title or what the surgeon understands the surgery title to be does not match how that procedure is described in the cpt guide and another cpt would be a better fit for what the surgeon did than the title listed on the operative report.

If you are only zooming in on the title of the op note and getting your cpt choice to match that title, one is prone to the mistake illustrated in the selective attention test, where participants were told to count how many passes of the ball occurred and in the process many missed seeing the gorilla enter the basketball player circle. If you haven’t seen this video or read about the psychology test, click on the URL below. It’s an excellent example of how hyper focus on one thing blinds you to other vital things going on at the same time.

I opened a word press blog months ago and did nothing with it. I couldn’t decide, did I want a personal blog? Did I want a career blog? And if I did a career blog in my field, surgical medical coding, what would I focus on and how could I do it so it was a stress reliever and not an overwhelming mental experience since my field can be so broad. I work for a hospital system and I code medical surgeries from multiple discipline’s and hospital observation visits . And if I do a career blog, how can I silence the voice in my head that shouts , ” whoa, who do you think you are to write on this topic ? You are no auditor and you are no consultant and you are not even planning on writing on the topic of passing coding exams so what would be the point ?”. I had no good rebuttal to these zingers.

So, I did nothing and just left the blog unwritten till now. I waited for clarity. I waited for courage. I waited till I figured, what’s the point in waiting- I”ll just do it like I’ve done most things in my life. I’ll do it and find clarity in the doing.

Waiting for clarity is like being a sculptor staring at a piece of marble, waiting for the statue within to cast off the unneeded pieces. Do not wait for clarity to spontaneously materialize- grab a chisel and get busy!

Steve Pavlina

Once I began writing, I decided to find an image for this first post. I was drawn to the photo above. She remind’s me of the work version of myself. Except my hair is usually more messy, my face is more scrunched and if its close to the last half hour of my shift, I”m in full internal angst mode -hoping and praying I will make my chart number quota for the day and my productivity report will be favorable for the week. But other than those exceptions, the concentration, the double screens, the contemplative pose- that fits the visual for my job, medical coding very well.

While, I can’t tell the age of the woman in the photo, if it was me, it would be 2 years short of 50, middle aged. Along with being physically middle aged, I’m also medically coding in the middle. Since I feel, writing is at its best when its focused on what you have personally experienced, I want to focus this blog on medical coding in the middle. The time when you have already passed all your credential exams and you have managed to get the first job and are now in the middle. The period when you ask yourself, how do I keep it interesting? How do I continue to advance and learn? How do I handle the productivity, quality and accuracy requirements? How do I not let that audit get in my head and cause me to lose confidence in my ability as I go forward? Those are good topics for me to begin my blog with.